Including the Dangers of Using St. John’s Wort to Treat Bipolar Depression
Nevertheless, St. John’s wort is the most well-known alternative treatment for depression and many people take it. However, there are absolutely some dangers in taking St. John’s Wort that you should know about, especially if you’re bipolar.
Warning – the following is information provided by me, a non-doctor. Please check all information out with an actual doctor if you’re at all concerned. Thanks.
St. John’s Wort is not “Safe”
One of the problems with herbal remedies is that people think they are “safe” because they are “natural.” Well, so’s lithium and I wouldn’t recommend chomping on that without a doctor’s supervision either.
Herbs do things. If they didn’t, people wouldn’t take them. St. John’s wort may not be FDA-regulated (a whole other problem) but it is, for all intents and purposes, a drug. This means it should be treated with the same caution as any other drug.
The Diagnostic and Statistical Manual of Mental Disorders (DSM), the manual that defines all mental illness in the US, is being revised and a new version is due out in 2013. One of the proposed changes to the DSM is to the diagnosis of mixed moods. This change is being proposed by a mood disorders workgroup. It aims to reflect clinical practice where doctors already refer to a “mixed” mood that doesn’t officially meet the DSM criteria. (As I noted, mixed moods are only technically recognized in bipolar type 1.)
Changes to the mixed mood diagnosis will help people with bipolar 1, bipolar 2 and unipolar depression get better treatment.
3 Things I’ve Learned About Mental Health This Week
In a continuation of the 3 New Things series, this week follows up on the British Psychological Society’s critique of the Diagnostic and Statistical Manual of Mental Disorders, version 5 (DSM-V), talks about irritable mood in bipolar disorder and expresses my general disdain for people who can’t report about mental health accurately.
1. Do bipolars know when they’re irritable?
Irritability is a symptom for both depression and mania/hypomania in bipolar disorder. This seems to suggest people with bipolar disorder run around biting the heads off of everyone we meet, but this isn’t the case. While I may feel angry and irritable, I, for one, can cover this up as I know it’s a symptom of the illness and not really me.
The interesting thing is, some patients don’t even consider themselves irritable because they have the ability to hide it. Note the following interesting quote:
Patients may not understand what elevated, or euphoric, mood means, so it may be necessary to define these terms. Similarly, the meaning of “irritable” may be unclear to patients. Many patients do not regard themselves as irritable if they can refrain from expressing their easy propensity to anger. Therefore, it is critical to emphasize that although the anger may not be expressed outwardly, the emotion of simply feeling irritable is significant.
From: Psychiatric Times, Mixed States in Their Manifold Forms: Part I
Which begs the question – do you ever consider yourself in an irritable mood? How do you know?
2. The British Psychological Society’s Critique on the DSM-V
Last week I asked if the British Psychological Society (BPS) was reputable as I questioned the motives behind their critique of the DSM-V revisions. It’s not that they don’t have their points, it’s just the points they’re making are copied-and-pasted to virtually every diagnosis either new to the DSM or not. It turns out my suspicions may have been wrong. The BPS does seem to be a genuine, reputable organization.
I came across an article in Psychiatric Times that explained issues with the BPS’s DSM-V critique beautifully – by blindly applying the same “feedback” to virtually every part of the DSM, their feedback has no weight at all and smacks of an agenda.
Even if they say something people should be listening to, it gets lost in the din of all the noise caused by putting the feedback where it doesn’t belong (article).
3. Reporting on Mental Health Issues is Appalling
I am not a reporter. I try to be a true, honest, accurate writer of credibility, but a reporter I never claimed to be. For actual reporters though, I rather think they have a higher bar.
Like, to write things that are accurate. Exhibit A:
The treatment [rTMS] hinges on the idea that every cell in the body has an electromagnetic field, and when this field is out of alignment, problems develop. RTMS then uses the highly focused magnets to realign a depressed person’s brain, and get it functioning properly again.
For the record, that is incredibly wrong and rather stupid. rTMS has nothing to do with cells having “electromagnetic fields” and there is no such thing as “realignment.” That all sounds like new age mumbo-jumbo which, in this case, takes actual science and turns it into nonsense. All I can say is that if you read something in the media, you’d better check out the facts yourself because it sure seems like the reporter isn’t going to bother.
rTMS uses a very strong, magnetic field that rapidly changes polarity to create an electrical current. This current activates neurons in a specific part of the brain just like electroconvulsive therapy, but without the cognitive side effects (or likely, effecacy rate).
Perhaps it’s too much to ask that a reporter understand those two sentences. Sheesh. (And for an extra dose of outrage, check out the comments, which can only be inflamed by the misinformation in the article.)
Until next week when I will learn more and try to do better.
As I mentioned, mixed moods are technically considered part of the manic phase of bipolar disorder and thus, by definition, are only a part of bipolar disorder type 1. However, those of us with bipolar type 2 can tell you we mix it up with the best of them.
So, in part II of this series on mixed moods in bipolar disorder, I look at mixed moods in bipolar type II.
Ask a Bipolar – What is a mixed mood in bipolar disorder?
As one of the Burble’s commenters mentioned, there seems to be a lack of good information on mixed moods available. After some Googling, I would tend to agree. While mixed mood episodes are pretty common for us bipolar folk, few people seem to be discussing it.
This is the beginning of a four-part series on mixed moods in bipolar disorder:
- Mixed Mood Episodes in Bipolar Type I
- Mixed Mood Episodes in Bipolar Type II
- Changes to Mixed Mood Episode Diagnosis in the Revision of the DSM
- Treating Mixed Mood Episodes
What is a Mixed Mood Episode?
By definition, a mixed mood in bipolar disorder is the presence of both depression and mania. According to the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), mixed moods are only present in bipolar disorder type 1 as mixed moods require the presence of mania.
Mixed mood episodes are (officially) found in bipolar disorder 1 and are characterized by:
- Persons must meet both the criteria for mania and major depression; the depressive event is required to be present for 1 week only.
- The mood disturbance results in marked disruption in social or vocation function.
- The mood is not the result of substance abuse or a medical condition.
Mixed mood episodes are officially considered part of the manic phase of bipolar disorder.
As requested, I’m going to provide the details on the custom mood / variables I use in the T2 Mood Tracker. These are just my variables, they certainly don’t have to be yours, but they might be good to glance over.
Custom Moods / Variables I Use to Improve Mood Tracking
As I mentioned, the more difficult a case you are, and boy am I difficult, the more challenging the patterns can be to find. This is why I’ve included these extra variables. Custom moods / variables include:
OK, you’ve sold me as to why I should track my mood (part 1); so just how do I track my mood?
Obviously, the simplest form of mood tracking is just recording depression and mania on a scale, say, of one-to-ten. You could use a “paper” and “pencil” (look it up on Wikipedia).
You might still notice mood trends but that type of mood tracking is not nearly as helpful as it could be. And the more complicated your case, the more you already know, the more subtle your shifts may be and the less you’ll see using simple methods.
There are far more useful, not to mention easier, options.
If you’ve been around for the last couple of weeks either at the Burble or at Breaking Bipolar, you know it’s been pretty much all suicide all the time. And there will probably be more to come on suicide as it’s an awfully big topic.
But I do have a question for everyone:
What topics would you like to see on the Burble?
Are there questions about me? Bipolar? Mental illness in general? A timely topic?
A reader recently suggested a topic on mental illness and euthanasia / right to die. A great idea. (Although really hard. Someone is clearly wanting me to tackle a rather large challenge.)
I can’t promise I’ll address all your questions / suggestions, but I would like to hear them nonetheless. Because if there’s one thing I’ve learned by writing the Burble for so long: Readers will surprise you.
So, you have the microphone. What mental health topics are you thinking about?
In part one I discussed the details of a study about 100 people who attempted suicide in Florida. Part two outlines the predictive factors for suicide attempts identified in this study and how we can use this information to predict who will attempt suicide.
And perhaps more importantly, how you can prevent a suicide attempt in a loved one.
Some of us in the mental health field have heard the suicide warning signs so often it’s practically tattooed on the back of our skull: suicide note, suicide plan persistent thoughts of suicide, previous suicide attempt and so on.
But if you think you know the warning signs for a suicide attempt you’re probably wrong, at least according to a study out of Florida. For example, fewer than 1-in-10 people leave suicide notes and fewer than one-third of people have persistent thoughts of suicide before their suicide attempt.
As I mentioned, people with bipolar type II spend 35X more time depressed than hypomanic, and yet there are very few treatments available.
As we discussed last time, the neurotransmitter glutamate and the inflammatory complex are two new, badly-needed areas of bipolar depression treatment research. Here are three additional bipolar depression treatment areas you probably don’t know about: diet, antioxidants and modafinil.
Diet, Insulin and Bipolar Disorder
There are quite a few people talking about diet and bipolar disorder, and diet and depression. And for all the words they say, the one thing we actually know through study is: no diet is known to treat bipolar disorder. Period. We know an unhealthy diet will possibly make you worse, but the only thing science can recommend is to eat a healthy, balanced diet.
Diet and Insulin
[push]The only thing science can currently recommend is to eat a healthy, balanced diet.[/push]
That being said, insulin interacts with many parts of the body responsible for much of the brain functioning. For example, insulin regulates the concentration of neurotransmitters and monoamines in the central nervous system; and these chemicals are thought to impact mood disorders, Alzheimer’s and schizophrenia. It appears a lack of insulin can produce mental illness symptoms.
This area is in extremely early development but there is currently testing of insulin increasing drugs in treatment of bipolar disorder and depression. And yes, other dietary issues are being studied (more carbohydrates and less carbohydrates are being studied) but as of yet, there is nothing concrete.
Antioxidants and Bipolar Depression (N-acetylcysteine (NAC))
We know something unfortunate about the brain and mental illness: mental illness shrinks the brain. (Mental illness decreases neuroplasticity, technically.) And we know that some drugs protect or reverse this effect (SSRI antidepressants, lithium, electroconvulsive therapy (ECT)). [pull]We know something unfortunate about the brain and mental illness: mental illness shrinks the brain.[/pull]
And one of the possible causes of brain shrinkage currently being considered is oxidative stress. Oxidative stress represents an imbalance that prevents detoxification and repair within tissues. (It’s complicated. See Wikipedia.) Some amount of oxidative stress is normal (and important) but this stress combined with cell abnormalities is implicated in bipolar disorder. Evidence suggests lithium and valproic acid protect neurons against oxidative stress.
(Still with me? Good. It’s going to get easier. Just hang on a bit longer.)
This oxidative stress can be caused due to decreased levels of antioxidants. One in particular, glutathione, is known to have abnormal levels in bipolar disorder. And in order to make enough glutathione, a body must have enough of an amino acid, cysteine.
Increasing cysteine levels using N-acetylcysteine (NAC) has been reported to be neuroprotective and impact glutamate (which we think is good, see here). NAC has been able to alleviate depressive symptoms in people with bipolar disorder in a double-blind placebo-controlled study as an add-on medication.
The good? NAC is cheap, over-the-counter, and from what we know, safe.* The bad news? NAC can take up to five months to work and study on it is limited. (See bipolar disorder type 2 depression and NAC notes by Dr. Jim Phelps.)
In a completely non-medical, Natasha-only-based opinion, NAC seems like something you could talk to your doctor about adding. There doesn’t seem to be a downside other than waiting for five months to see if it works. This doesn’t mean try it on your own. It means talk to your doctor.^
Modafinil and Bipolar Depression
Last, but not least, is the research into modafinil treatment of bipolar depression. Modafinil is a “wakefulness promoting agent” prescribed to people “with excessive sleepiness.” This is not an amphetamine but is a stimulant. Basically, we don’t understand this medication but it increases monoamines like norepinephrine and dopamine, which we generally like.
Modafinil has been shown effective in treating bipolar depression (without inducing mania or hypomania) by week two of treatment. In the study, modafinil decreased depressive symptoms and increased remission rates.
This medication is one some doctors are already using off label for the treatment of bipolar depression.
Summary of Bipolar Depression Treatments You Didn’t Know About
Basically, under all of this, the message is: we’re working on it. It’s long and slow and frustrating for us crazies but the doctors have their lab coats out and they’re thinking up stuff all the time. Will any of these help you? I don’t know. But what I do know is these five areas should be a reason to hold onto hope, even if what you’re doing right now isn’t working.
The information in this article is primarily from: Novel Treatment Avenues for Bipolar Depression By Roger S. McIntyre, MD and Danielle S. Cha. Clinical Psychopharmacology. April 19, 2011.
See the article for all the nitty gritty details about the above.
* Safe in this case means no known drug interactions (to the best of my knowledge and according to a doctor). In the drug database used by doctors up here in Canada it reports no side effects. In the study they note it as “safe” but report change in energy, headaches, heartburn and joint pain as possible side effects – these being basically the same in the placebo and NAC group. Keep in mind though, so little study has been done on this there may be all sorts of gotchas we haven’t seen.
^ Remember: your doctor should know about all medications, vitamins and supplements you take. Just because it’s over-the counter doesn’t mean it’s harmless.
People with bipolar disorder 2 spend 35 times more time depressed than hypomanic. As a person with bipolar type 2, I can tell you how true this is. Bipolar type 2 is more like a depressive disorder than a bipolar one. However, this doesn’t mean bipolar disorder 2 can just be treated like unipolar depression. If only life were that simple.
Bipolar disorder type 2 depression treatments must not induce hypomania or mania, and antidepressants used alone often do that. For this reason bipolar 2 depression treatment is generally like happy hour (full of cocktails). And many of us are very frustrated with the fact no new medications are being developed for our mental illness.
So here’s some hope. Here are five bipolar depression treatment areas you probably don’t know about.